Babinski, Leslie M.

Bai, Yu

Gifford, Elizabeth J.

Miller, Shari

Troop, Tony O.

Wells, Rebecca

PubMed

Carolina Digital Repository

Pairing Nurses and Social Workers in Schools: North Carolina’sSchool-Based Child and Family Support TeamsElizabeth J. Gifford, PhDa [Research Scientist], Rebecca Wells, PhDb [AssociateProfessor], Yu Bai, PhDc [Statistician], Tony O. Troopd [Program DevelopmentCoordinator], Shari Miller, PhDe [Research Psychologist], and Leslie M. Babinski, PhDf[Research Scientist]Elizabeth J. Gifford: beth.gifford@duke.edu; Rebecca Wells: rwells@unc.edu; Yu Bai: yb17@duke.edu; Tony O. Troop:tony.troop@dhss.nc.gov; Shari Miller: shari@rti.org; Leslie M. Babinski: leslie.babinski@duke.eduaDuke University, Box 90545, Durham, NC 27708.bGillings School of Global Public Health, Department of Health Policy and Management,University of North Carolina McGavran-Greenberg, CB# 7411, Chapel Hill, NC 27599-7411.cDuke University, Box 90545, Durham, NC 27708.dSchool Based Child & Family Support Team Initiative, NC Division of Public Health, Women’sand Children’s Health Section, Mail Service Center 1928, Raleigh, NC 27699-1928.e3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709-2194.fDuke University, Box 90545, Durham, NC 27708.When children are struggling in school, underlying causes often include physical orbehavioral health problems, poverty, abuse, and/or neglect. Children’s poor physical healthstatus has been linked to deficits in memory and reading ability.1 Children with behavioralproblems are much more likely than others to have lower grades, miss school, be suspendedor expelled, and drop out.2–4Access to needed health and human services is critical to vulnerable children’s success inschool. Yet, need often does not predict use. Approximately, 7% of children overall have anunmet need for health care, with the poor, near poor, and uninsured being 3 times morelikely than their peers to be underserved.5 Only about 1 in 5 children in need of mentalhealth care receive services.6Even available services are often fragmented, making it more difficult for families both toaccess and utilize them effectively. Increasingly, the federal government, child advocacygroups, and private funders are therefore encouraging any organization that identifies an at-risk child, to convene a team including representatives of all relevant agencies. These teamsshould include parents as full partners to identify both child and parent needs and to buildservice plans on strengths as well as needs.7 Given their primary role in children’s lives,schools are a logical base for such coordination.The current article describes an innovative effort in North Carolina to help at-risk childrenthrive academically and remain with their families: the school-based Child and Family© 2010, American School Health AssociationAddress correspondence to: Elizabeth J. Gifford, Research Scientist, (beth.gifford@duke.edu), Duke University, Box 90545, Durham,NC 27708.NIH Public AccessAuthor ManuscriptJ Sch Health. Author manuscript; available in PMC 2012 August 10.Published in final edited form as:J Sch Health. 2010 February ; 80(2): 104–107. doi:10.1111/j.1746-1561.2009.00472.x.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptSupport Team Initiative (CFST). The following provides an overview of the program and aprofile of the children served in the program’s first 2 years.PROGRAM OVERVIEWIn 2005, the North Carolina General Assembly established the school-based CFST tofacilitate service access for children at risk of school failure or out-of-home placement.Beginning in 2005–2006, state funds have supported 1 certified school nurse and 1 licensedschool social worker in each of 101 schools with a large proportion of high-risk studentsacross the state. These CFST leaders are funded to work full time on CFST.8 CFST leaders’primary duty is to coordinate services for at-risk students among education, health, socialservice, and juvenile justice agencies. They engage with families who have been referred tothe program, determine if a CFST is the appropriate resource for the family, schedule andfacilitate team meetings with parents, service providers, and community partners, andmanage cases, and monitor students’ progress. Child and Family Support Team Initiativeleaders make home visits to meet the parents who lack transportation, to build trust amongfamilies who have disconnected from the school system, and to become familiar with thestudents’ home environment. In most schools, the nurse and social worker fully shareresponsibility for the majority of cases. In other schools, the nurse and social worker eachassume the lead on cases based upon their relative expertise. In either instance, the nurse andsocial worker support one another throughout this intense process.A key component of the CFST initiative is the involvement of multiple agencies, includingthe Departments of Public Instruction (DPI), the Administrative Office of the Courts, theDepartments of Juvenile Justice and Delinquency Prevention (DJJDP), Health and HumanServices (DHHS), Public Health, Social Services (DSS), and Mental Health, DevelopmentDisabilities, and Substance Use (DMH/DD/SAS). Each agency was charged with workingtogether through this program.Program components of the CFST model include child and family team meetings, serviceplans, and a Web-based case management system. Each one is described below.REFERRAL PROCESSAccording to the CFST model, any school faculty or staff member may refer a student to theCFST nurse or social worker for any of the following reasons: academic factors (eg, retained1 or more years, failed 2 or more classes in a recent semester, sudden drop in grades),excessive absences (eg, excessive tardiness, skips class, leaves early, suspensions), or“inappropriate social interactions” (eg, aggressive or inappropriate behavior, delinquentactivities, victim of bullying, withdrawn/change in behavior), and health and human serviceneeds (eg, health and/or mental health concerns, developmental issues, suspected substanceuse, pregnant/parenting or income related).Once a CFST leader receives a referral, he or she assesses the student’s needs by meetingthe parents and gathering information from those who best know the student (includingconversations with the student). Nurses and social workers also periodically visit youths’homes to learn more about family situations and introduce themselves to families. They thenschedule a meeting with the student’s parent or guardian and other adults who have investedin the child’s success (such as ministers and coaches), the student (if sufficiently mature),and representatives of any health and social service organizations believed to be relevant tothe child’s needs.Gifford et al. Page 2J Sch Health. Author manuscript; available in PMC 2012 August 10.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCHILD AND FAMILY TEAM MEETINGSMeetings are held at a time that the family can attend—often evenings or weekends. Aprimary objective of the initial meeting is to establish goals for the child that build on childand family strengths and a strategy to achieve those goals, including a plan for all necessaryhealth and social services. Instead of having separate case plans with each agency, the childand his or her family should have a single plan integrating all service providers, a goalsummarized as “1 child, 1 family, 1 plan.” The agency relevant to the student’s primaryunmet need is charged with leading the CFST (eg, school staff lead for academic issues, abehavioral health provider leads for behavioral health problems, or social services lead whenthe primary unmet need relates to child abuse or neglect). Through subsequent meetings, thegroup monitors progress and adjusts plans as the child’s situation changes.Research has linked interagency teams to additional receipt of services for children in childwelfare as well as sometimes decreased recidivism rates.9 When a United Kingdom socialservices department used a form of child and family teams in 16 schools, parents andstudents were satisfied with the program and attendance and behavior improved.10CASE MANAGEMENT SYSTEMNurses and social workers enter data on students referred by the CFST program via a Web-based case management system. The information includes student demographics (age, race,ethnicity, gender, grade, special education status), academic, health, and social serviceneeds, team meetings, services plans, follow-up on service plans, and reasons why casesclose. These data are used in several ways. First, CFST leaders can track students’ needs andensure receipt of services. Second, aggregate reports allow CFST staff to examine trends intheir schools that may inform decisions about where to make additional investments inservices. Third, state officials use this information to monitor the program and modelfidelity. Finally, the evaluation team at the Center for Child and Family Policy at DukeUniversity is using data from the case management system to assess program impact onacademic outcomes by comparing children served through CFSTs to children in comparableschools who have not been served through CFSTs.PROFILE OF CHILDREN AND YOUTH SERVEDDuring the first 2 years of the program (the 2006–2007 and 2007–2008 academic years),15,680 students were referred to the program and entered into the case management system,of whom 13,902 (89%) had information on needs listed.About half of the students in the system were in elementary school, 27% were in middleschool, and 24% were in high school. Boys made up 54% of those referred. The racial andethnic composition of the students referred to the CFST program roughly matches thecomposition of the schools. For example, 53% of children referred to the CFST programwere African-American relative to 53% of the student body in CFST schools. Similarly,Latinos represented 11% of the students referred to the CFST program and constitute 12%of the school body. American Indians represented 3% of CFST referrals and 3% of overallschool population.Of the students referred, 73% had an academic problem, 56% a health problem, 49% amental health, substance use, or developmental need, 65% a social service need, and 6% alegal need. As shown in Figure 1, 77% of students served by CFST had needs that related tomore than one sector. One third (31%) had 2 needs, 22% had 3 needs, another 21% had 4needs, and 3% had 5 needs.Gifford et al. Page 3J Sch Health. Author manuscript; available in PMC 2012 August 10.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptIMPLICATIONS FOR SCHOOL LEADERSHIPNorth Carolina’s CFST Initiative shows how schools can facilitate access to the health andhuman services that the vulnerable children need for stability and success. To help studentsachieve academically, CFST leaders connect students and families to resources such astutoring, mentoring, counseling, eye glasses, hearing devices, food stamps, housing support,and after-school activities. The nurses and social workers help families initiate behavioralhealth care for issues such as depression, anxiety, or dealing with family events such asdeath or illness. They also help families address barriers to receiving services such as lack oftransportation. For example, in some school systems the CFST leaders can drive students toservices. In other communities, nurses and social workers host meetings in locations easilyaccessible for families such as churches or community centers.Of course new models always encounter new challenges. Because some CFST schooldistricts are in very rural counties and nurses could earn higher salaries in other jobs,recruiting qualified nurses has been challenging in a few locations. During the early stagesof implementation, a few principals were wary of nurses and social workers leaving schoolgrounds to make home visits and of offering the compensatory time necessary forscheduling evening, early morning, or weekend meetings.Another challenge has been clarifying and communicating the difference between a CFSTnurse and a traditional school nurse. In the CFST program, both nurses and social workersaddress a range of issues affecting academic performance, potentially including familyhealth, social service, and material needs. Unlike most traditional school nurses, CFSTnurses serve the population of only 1 school, and address students’ needs beyond thosepertaining to physical health concerns. If the school had a nurse prior to the CFST initiative,CFST funds could not supplant dollars used for this nurse’s salary. Yet, CFST nurses insome schools still routinely receive referrals of children with the types of isolated physicalmaladies best handled by traditional nurses. Although some nurses have reported significantdifficulty communicating the nature of their CFST role to colleagues and parents, manyhave noted satisfaction from developing deeper and more enduring involvement withfamilies.At the same time, having a nurse work with a social worker has presented some unexpectedopportunities. For instance, when a CFST nurse and social worker visit a home, often thenurse will knock on the door. Experience has shown that families are much less wary ofnurses than of social workers, whom they associate with child welfare.When children’s needs are unmet, schools are often the first to identify potential problems.North Carolina’s school-based CFST initiative allows schools to create coordinated healthcare plans so that every student receives the support she/he needs to achieve academicsuccess.REFERENCES1. Kramer RA, Allen L, Gergen PJ. Health and social characteristics and children’s cognitivefunctioning: results from a national cohort. Am J Public Health. 1995; 85:312–318. [PubMed:7892911]2. Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. Utility of psychosocial screening at aschool-based health center. J Sch Health. 2000; 70(7):292–299. [PubMed: 10981284]3. Wagner M, Cameto R. The characteristics, experiences and outcomes of youth with emotionaldisturbances. NLTS2 Data Brief. 2004; 3(2) Available at: www.ncset.org/publications/viewdesc.asp?id=1687.Gifford et al. Page 4J Sch Health. Author manuscript; available in PMC 2012 August 10.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript4. Wagner, M.; Newman, L.; Cameto, R.; Garza, N.; Levine, P. Menlo Park, CA: SRI International;2005. After High School: A First Look at the Postschool Experiences of Youth With Disabilities. Areport from the National Longitudinal Transition Study-2 (NLTS2). Available at:www.nlts2.org/reports/2005_04/nlts2_report_2005_04_complete.pdf.5. Newacheck PW, Hughes DC, Hung Y-Y, Wong S, Stoddard JJ. The unmet health needs ofAmerica’s children. Pediatrics. 2000; 105(4):989–997. [PubMed: 10742361]6. Burns BJ, Angold A, Tweed D, et al. Children’s mental health service use across service sectors.Health Aff (Millwood). 1995; 14(3):147–159. [PubMed: 7498888]7. Leaf, PJ.; Schultz, D.; Kiser, LJ.; Pruitt, DB. School mental health in systems of care. In: Weist,MD.; Evans, SW.; Lever, NA., editors. Handbook of School Mental Health: Advancing Practice andResearch. New York, NY: Kluwer Academic/Plenum Publisher; 2003. p. 239-256.8. Troop T, Tyson CP. School nurses, counselors, and child and family support teams. N CMed J.2008; 69(6):484–486.9. Baffour TD. Ethnic and gender differences in offending patterns: examining family groupconferencing interventions among at-risk adolescents. Child Adolesc Soc Work J. 2006; 23(5–6):557.10. Crow, G.; Marsh, P.; Holton, E. Family and Welfare Findings Series. University of Sheffield;2004. Summary findings-supporting pupils, schools and families: an evaluation of the HampshireFamily Group Conferences in Education Project.Gifford et al. Page 5J Sch Health. Author manuscript; available in PMC 2012 August 10.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 1. Students Served by the CFST Program in 2006–2007 and 2007–2008: Number ofSectors That Their Needs CrossSource: Authors’ tabulation of the NC School-Based CFST case management data.Gifford et al. Page 6J Sch Health. Author manuscript; available in PMC 2012 August 10.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript

Pairing Nurses and Social Workers in Schools: North Carolina's School-Based Child and Family Support Teams

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Pairing Nurses and Social Workers in Schools: North Carolina's School-Based Child and Family Support Teams

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